A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following based on this score?

The nurse provides education to a patient who is diagnosed with trigeminal neuralgia. Which patient statement indicates the need for additional teaching?

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? Select all that apply.

A nurse is caring for a client who requires intervention for acute crisis. Which of the following actions is the highest priority?

A nurse is teaching a newly-admitted client about the possible physical effects of alcohol withdrawal. Which of the following manifestations should the nurse include in the teaching? Select all that apply.

The nurse is performing an initial assessment on a newly admitted patient who is oriented times four. Which of the following communication techniques would best facilitate obtaining accurate and complete patient data?

A manic client beings to make sexual advances towards visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on analysis of this situation, which intervention should the nurse implement?

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, “I’m finally cured.” How should the nurse interpret this behavior as a cue to modify the treatment plan?

Part 3 of 3 A nurse is caring for a client who has schizophrenia. Medical History Client admitted with long-standing history of non-adherence to medication regime (haloperidol 40 mg PO daily) and recreational drug use. Client presents with positive symptoms including disorganized and bizarre thoughts, persecutory delusions, and use of neologisms. Will start client on haloperidol 10 mg IM every 6 hr while hospitalized. Vital Signs Blood pressure: 192/100 mm Hg Temperature 39.6º C (103.3º F) Heart rate: 126/min Respiratory rate: 24/min O2 saturation: 92% on room air Nurses Notes Client found lying on bed in room. Sluggish response to verbal commands. Incontinent of urine. Skin diaphoretic and hot to touch.  Extremities are rigid. Vital signs obtained and provider notified. Which TWO parameters are most important to monitor for this patient?

The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client’s speech pattern is rapid, and affect is belligerent. Based on these observations, what is the nurse’s immediate priority of care?